直视下开放鼻截骨技术的临床应用

Open osteotomy in rhinoplasty

目的介绍一种新的鼻背外侧截骨方法。该方法的核心是通过对梨状孔周围组织的充分剥离,达到在直视下进行鼻骨截骨的操作;整个操作过程截骨线的走行可见,为术中截骨程度的掌握提供更可靠的控制,也使得术后的转归具有更大的可预见性。方法回顾性分析2018年10月至2020年8月为改善鼻部外观在中国医学科学院整形外科医院就诊的鼻整形患者资料。所有患者采用直视下开放外截骨联合自体肋软骨植入隆鼻术(伴或不伴驼峰鼻矫正术)。术中显露鼻骨及上颌骨额突,截骨过程全程在直视下进行,达到对于截骨线走行即时评估的目的。手术后对并发症发生情况和患者鼻部形态进行随访。由患者对手术效果进行满意度自评;同时,根据术前和随访时的照片,由第三方医生进行观察者总体美容改善评分(IGAIS)的评价。结果本组共纳入33例患者,均为女性,年龄19~34岁,平均25岁。所有手术过程顺利,术后局部均有不同程度肿胀。随访时间为3~18个月,3个月后鼻部轮廓及曲线基本稳定。所有患者未发生感染,以及鼻泪管、泪囊、内眦韧带、神经损伤及感觉障碍等并发症。有2例患者术后半年随访时发现鼻骨有轻度增宽的表现,但患者本人未要求行二次手术干预。患者外鼻形态均一次性得到较大改善。患者对手术效果均感到满意,自评情况为:非常满意24例(72.7%),满意9例(27.3%)。医生的IGAIS评估结果亦得到正面评价:33例患者的评分为(1.26±0.34)分,其中1分30例(90.9%),2分3例(9.1%)。结论在直视下进行截骨操作相较盲视操作的精度更高,效果更可靠。无论是对初入鼻整形领域的青年医师,亦或是有经验的外科医生而言,操作过程更安全,具有更好的临床实践可行性。

Objective To introduce a new method of lateral nasal osteotomy.The key of this method is to fully dissect the tissue around the piriform foramen to achieve nasal osteotomy under direct vision.The osteotomy line in the whole process can be seen,which provides a more reliable control for the degree of osteotomy during the operation,and also makes the postoperative outcome more predictable.Methods Patients whom were treated with open external osteotomy combined with autologous costal cartilage implantation for augmentation rhinoplasty(with 24 cases of hump nose correction)from October 2018 to October 2020.During the surgery,the whole nasal dorsum was exposed,the superior lateral cartilage was separated from the nasal septum,and the whole process was carried out through the mucosa from the intranasal approach under direct view.The osteotomy line was evaluated at the same time.Results A total of 33 female patients were retrospectively analyzed.All the operations were successful,and the local swelling occurred after operation.The follow-up time was 3-18 months.After 3 months,the nasal contour and dorsal curves were smooth.Severe infections,major injuries like nasolacrimal duct,lacrimal sac,medial canthus ligament,nerve branches were not noticed in all patients.During the long-term follow-up,two patients exhibited slightly widened nasal bone,but did not require surgical intervention.The shape of nose was greatly improved.Patients were satisfied with the result.The subjective evaluation had"very satisfactory"in 24 cases(72.7%)and"satisfactory"in 9 cases(27.3%).The IGAIS evaluation were also positive:the average score of 33 patients was 1.26±0.34,including 30 cases(90.9%)scoring 1 point and 3 cases(9.1%)scoring 2 points.Conclusions The open osteotomy technique has better control than that of conventional blind operation.It is more reliable,safer for the surgeons who are new to rhinoplasty and the experienced ones.